Opioid explosion: Stanislaus County residents got 218 million pills in seven years

Aug. 20--In a seven-year span, Stanislaus County pharmacies received over 218 million prescription pain pills -- hydrocodone and oxycodone: Enough for 61 pills per person, per year in the county.

"I remember how overwhelming it was, even in residency, how many patients were on narcotics," said Dr. Lyn Raible, the recently retired chief medical officer for Aegis Treatment Centers, who trained at the Stanislaus County Family Medicine Residency Program from 1999 to 2002.

The data were included in a recent national study conducted by The Washington Post. The numbers soared during the seven-year period, increasing from 25 million distributed in 2006 to 36 million distributed in 2012. There were about 98 prescriptions per 100 people in 2006, increasing to about 112 prescriptions per 100 people in 2012, according to the Centers for Disease Control and Prevention rate maps.

Though Stanislaus County made up about 1.37% of California's population in 2012, it received 2.71% of the pills sent to the state during the seven-year period, according to an analysis of the data by The Modesto Bee.

Since 2006, about 316 people have died from opioid overdoses in the county.

As a physician focused the past several years on the treatment of opioid addiction, Raible can recount how the declaration of pain as the fifth vital sign by the Joint Commission, known as the Joint Commission on Accreditation of Healthcare Organizations at the time, in 2001 changed how doctors prescribed opioids.

The five vital signs are body temperature, blood pressure, pulse, breathing rate and pain. They are the first things evaluated and treated. All have baseline normals, and if anything is off, it indicates a problem.

"It put doctors in a very difficult position because if the patient complained of pain, (doctors) would be punished," Raible said. So, she added, doctors began prescribing more opioids to avoid repercussions by their employers.

They had few other options, Raible said, as pain management clinics are often unobtainable for many and other treatment options go relatively untouched by the insurance companies. To keep their patients happy and to satisfy the fifth vital sign standards, doctors prescribed more opioids than ever.

'I always had plenty'

For Dale Cook, a former Modesto resident who now lives in Pioneer, the epidemic is personal.

His brother passed away in 2004 after being addicted to oxycodone for years. After going into kidney failure, Cook said, his brother became brain-dead.

"I was called to the hospital because I had power of attorney over my brother's life," Cook said. "His soul was already gone ... so I told the doctors to turn off the life support. It took him one minute and 52 seconds to die."

"He was my baby brother. There's not a day that goes by that I don't think of him."

Years later, Cook found himself addicted to opioids.

Cook had prescriptions for 360 pills a month -- 120 oxycodone, 120 Vicodin doses, containing 5mg hydrocodone and 500mg paracetamol, and 120 Soma 350mg, a muscle relaxer that often leads to a greater risk of narcotic addiction.

"I always had plenty," Cook said.

He was prescribed the high-dosage opioids after a car accident destroyed his right shoulder, which required replacement. After getting hooked, Cook's life began to deteriorate.

"My wife thought about leaving me; my daughter didn't speak to me," he said. "I just wanted to be high all the time."

Cook doesn't remember an entire year and a half of his life because of a devastating stroke and subsequent seizure he said might have been caused by his addiction to the medication. Because of how his addiction was impacting his family's life, Cook's wife pushed him to quit.

Now, Cook is prescribed Norco 10-325 -- a combination of 10mg of hydrocodone and 325mg of acetaminophen -- at about half the dosage of oxycodone he was getting before. Because he still feels pain and needs another shoulder replacement, Cook said, the opioid is necessary and works for him. Additionally, he doesn't get the same high from it as from oxycodone.

"I have 120 tabs, and I take one pill three times a day," he said. Though he is prescribed enough for one pill four times a day, Cook said, he only takes the extra pill if he does yard work or other labor-intensive work that causes his shoulder's pain to flare up. Sometimes he supplements his medication with CBD, or cannabidiol, gummies to ease the ache further without taking more opioids.

"I can function now; I can think," he said. "I will never, ever go back to that medication ever again."

'Our society is one of pill-taking'

Before 2001, a patient's pain was not treated as aggressively and doctors were not pushed as hard to prescribe stronger drugs.

"When I first started training back in 1994, we didn't see this as a problem," said Dr. Silvia Diego, a family care physician in Modesto. Doctors would prescribe some pain medications, Diego said, but only the very sick and in the most extreme pain would get any pills. But things have changed, and many hope a simple pill will be their one-stop shop to quell their pain.

"Our society is one of pill-taking," Diego said.

Once doctors were required to treat pain as a fifth vital sign, they began rolling out more prescriptions, with more pills in each bottle, Diego said. Drug manufacturers and distributors also were working hard to promote and advertise their products, such as OxyContin, as better and less addictive for patients, leading to many current-day lawsuits in several states, including California.

"Some people would get addicted to (opioids) ... Other people would build a tolerance," Diego said. "And before you knew it, 30 pills a month wasn't enough for them. They needed 60 pills.

"It did get out of hand, and there were a lot of pills being prescribed."

But doctors were going by what they thought was best for the care of the patient, Diego said, and opioids are necessary sometimes with extreme, chronic pain.

It wasn't until January of 2016, when studies emerged showing opioid overdose deaths had surpassed car crash deaths, that doctors -- and the government -- took notice.

The U.S. Food & Drug Administration subsequently called for a "sweeping review of agency opioid policies" in February of 2016. The CDC established guidelines a month later, similar to the Medical Board of California's guidelines, that essentially put a suggested ceiling on the dosage of opioids that patients were prescribed.

Doctors began to think more about if a patient needed three weeks worth of postoperative opioids, or just three days.

"When you're off work for six to eight weeks for major surgery, it would make sense to have pain pills for that whole time," Diego said. But in reality, she added, pain typically only lasts for a few days after surgery, and if it persists, there may be underlying complications that should be addressed in other ways outside of just prescribing more pain medications.

The new guidelines also brought some concern as well as doctors would suddenly cut their patients off of opioids after relying on the drugs.

"It's stressful -- at first, they were getting punished for if their patient was complaining of pain; now they're worried about losing their license if they prescribe more opiates," Dr. Raible said. "We now have doctors who are improperly cutting patients off of these narcotics. And so (the patients) start buying it on the streets, and then they find out that black tar heroin is cheaper than pills."

Opioid prescriptions in Stanislaus County reached an all-time high of about 575,691 prescriptions in 2012, according to the California Department of Public Health's Opioid Dashboard. By 2017, that figure decreased to 529,832 prescriptions, about an 8% decrease.

Though not all of those prescriptions are specifically for hydrocodone or oxycodone pills, the National Institutes of Health reports that they are among the most commonly prescribed.

Comparably, in 2012 only about 3,390 prescriptions of buprenorphine were written in the county, according to the CDPH's Opioid Dashboard.

Suboxone, which contains both buprenorphine and naloxone, is a common drug that can be prescribed to fight both pain and drug addiction. The drug does not produce the same high as other opioids do while also treating pain, making it far less addictive. According to the CDPH's Opioid Dashboard, increasing numbers of prescriptions with buprenorphine signal increasing access to addiction treatment.

For Stanislaus County, the number of buprenorphine prescriptions has nearly doubled since 2012.

Obtaining a medical waiver specifically to administer buprenorphine is complicated, though, as it requires physicians to complete eight hours of training and qualify for a practitioner waiver. But physicians are already qualified to prescribe opioids like hydrocodone and oxycodone without any additional training.

Treatment options still unobtainable for many

For those seeking medically assisted treatment for opioid addiction, the options in the county have struggled to keep up with high demand.

"We have around 900 patients at Aegis," Raible said, adding that they still have hundreds on the waiting list, despite efforts and funding from the county and state.

"I know people have died waiting to get treatment," she said. "They overdose or something else happens before we can help them."

A 2006 study by UCLA's David Geffen School of Medicine says that "substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487 ... These benefits were primarily because of reduced costs of crime and increased employment earnings."

Stanislaus County, in an attempt to address the opioid epidemic in the county, created an Opioid Safety Coalition last year and held a summit in March.

"Our main mission is about education," said Dr. Bernardo Mora, medical director of the county's Behavioral Health and Recovery Services. "We are still in the relatively early stage of assessing and seeing where the needs are and getting folks connected."

The county has recently entered a $45 million Drug Medi-Cal Organized Delivery System (DMC-ODS) contract from the DHCS that allows the county to expand its current level of substance abuse treatment and hire more staff, said Cameo Culcasi, a substance use disorder manager for the county.

Regardless, the treatment available for those who need it is still lacking, Mora said.

Culcasi said that with the new DMC-ODS waiver, the county may be able to slowly alleviate the stress on the treatment centers.

"If (those addicted to opioids) ask for substance abuse treatment today, they are at their peak motivation," she said. "But tomorrow that could change. So trying to morph and build a system to work with that takes time."

Stanislaus County is no stranger to opioid addiction, but the funds to support adequate treatment, as well as the undue stigma, are still catching up with the epidemic.

"We don't blame people with Type 2 diabetes for having a pancreas that doesn't produce enough insulin," Raible said, arguing that opioid addiction is largely a genetic predisposition.

"We think that you have to work hard to get addicted because, for most people, they don't feel good and energized after taking the pills," she said.

For someone like Dale Cook, who has seen addiction take a family member's life -- and almost his own -- opioids like oxycodone are still a haunting substance.

"We have to get the epidemic under control," he said. "When it comes to addiction, the only way to solve the problem is to admit you have a problem."

By The Numbers

-- From 2006 to 2012, over 218 million prescription pain pills were distributed in Stanislaus County.

-- In 2012, Stanislaus County made up about 1.37% of California's population but received 2.71% of the pills sent to the state during the seven-year time period.

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There were 575,691 opioid prescriptions in 2012, an all-time high for the county.

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Since 2006, about 316 people have died from opioid overdoses in the county.

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